Frequently Asked Questions

• HUP CPR, a potentially significant advance in the care of OHCA patients based upon a decade of animal and humans research, was recently introduced to complement current BLS CPR techniques.

  o With the current standard of resuscitation care for BLS providers: a pair of hands, bag-valve ventilation, and a defibrillator, > 90% of all out-of-hospital cardiac arrest (OHCA) patients die1. These grim outcomes have remained constant for over 50 years, with very few major improvements to the standard of care.

  o Today’s ‘gold standard of care’ does not work for 90% of all OHCA patients, especially the 80% for whom defibrillation is not an option. Both animal and human studies provide strong support for using HUP CPR in a complementary manner to today’s standard of care for all OHCA patients.

  o In the war against OHCA, it will take many incremental advances before we can claim victory. With a national neurologically intact OHCA survival of 7.5 percent or less1 we strongly encourage evaluations, whether they are observational, prospective and/or randomized in nature, of new and promising approaches for the treatment of OHCA. To the extent possible, the evaluations should be rigorous and outcomes data should be collected and published.

  o We know there are no OHCA treatment silver bullets. Like every other complex and lethal disease state, multiple concurrent therapies, when delivered in a timely and appropriate manner, can be lifesaving. Building on the science of ACD-CPR and the ITD (the only FDA-approved approach to increase the likelihood of survival from OHCA), HUP CPR may be one of those incremental advances that shows great promise for patients in OHCA.

  o The medical community is often slow to embrace new ideas and therapies, even those based upon physics and the biological sciences. It takes an average of 17 years for a proven therapy to become standard of care. Advances in resuscitation science are desperately needed. Done correctly, HUP CPR offers great promise without known safety concerns 2,3. Unless and until we embrace new possibilities with enthusiasm and determination for better results, our patients will continue to die.

• HUP CPR combines suction cup-based CPR with an impedance threshold device (ITD) and a CONTROLLED SEQUENTIAL ELEVATION of the head and thorax to maximize blood flow to the brain and vital organs during sudden cardiac arrest. HUP CPR is built on the physiological platform of suction cup-based CPR plus an ITD and is complementary to conventional CPR, the current BLS standard of care.

• Over the past decade, HUP CPR has been shown in multiple animal studies to increase cerebral blood flow and coronary perfusion pressure, and to harness gravity to lower intracranial pressure relative to conventional CPR4-11.

• Each element of the HUP CPR approach has been FDA cleared and deemed safe to use. This includes suction-cup based CPR (ResQPUMP®, LUCAS®, or ARM XRTM), Impedance Threshold Device (ResQPOD®) and controlled patient positioning (EleGARDTM Patient Positioning System).

  HUP CPR is a methodical process – it is not a single device but rather a technology-based approach to resuscitation that complements the current AHA-recommended standards of care.

• Based on the laws of gravity, multiple animal studies have shown that with HUP CPR, intracranial pressure is reduced, and coronary and cerebral blood flow improved4-11. Human and animal studies have also shown improved survival outcomes3,12-14 relative to conventional CPR.

• HUP CPR uses circulatory adjuncts to pump blood ‘uphill.’ HUP CPR should be performed initially for ~2 minutes, with ~12cm of head elevation, to initiate drainage of blood from the head and thorax and ‘prime’ the cardio-cerebral circuit. Gradual elevation is then performed over another 2-minute period to maintain a

  perfusing aortic pressure while minimizing loss of pressure with elevation2-6,15,16.

• Ineffective HUP CPR includes no priming period, elevating the head rapidly, performing conventional CPR with head elevation, and not using an ITD5,6,15,17-19.

• The Do’s and Don’ts of Head Up CPR need to be followed to have a positive patient outcome17 (Appendix 1).

• The mechanism of Head Up CPR was well described by a thought leader in the field of Anesthesia, Dr. Shafer: HUP CPR is intuitive, obvious in retrospect, and an important advance20 (Appendix 2).

• Ineffective HUP CPR includes no priming period, elevating the head rapidly, performing conventional CPR with head elevation, and not using an ITD5,6,17-19.

• When HUP CPR is not done correctly it may result in poor outcomes15,19.

• When applied early, HUP CPR (n=227 patients) was associated with a statistically significant 3-to-5-fold higher hospital discharge rate and a 3-to-5-fold higher favorable brain function rate compared with conventional CPR, regardless of the presenting rhythm14. Conventional CPR patients were matched with the HUP CPR patients for age, sex, 9-1-1 call to start of EMS CPR, initial rhythm, bystander CPR rate, and witnessed status, to reduce the potential for differences in these variables that are also known to affect outcomes. The HUP CPR patients came from 6 EMS agencies across the country. The control patients came from 3 previously published clinical trials.

• In patients with a non-shockable rhythm (n=380 patients), when HUP CPR was applied by first responders there was a 3-to-5 fold higher likelihood of hospital discharge rate and a 3-to-5-fold higher favorable brain function rate compared with conventional CPR3. Patients presenting in PEA treated with HUP CPR were 9.8% neurologically intact compared with 3.3% treated with conventional CPR. Conventional CPR patients were matched with the HUP CPR patients for age, sex, 9-1-1 call to start of EMS CPR, bystander CPR rate, and witnessed status. The HUP CPR patients came from 5 EMS agencies across the country and control patients came from 2 previously published clinical trials.

• HUP CPR (n=1449 OHCA patients between 2021 to July 2023) from 7 EMS agencies from 7 states, were compared with 286,525 patients from the US National CARES data from 2021-2022 (the standard of care)21. CARES OHCA were generally treated with conventional CPR, with some minority of patients treated with automated CPR and or an ITD. For all patients, all rhythms, hospital discharge rates were 42.5 % higher in the HUP CPR patients versus patients from the CARES registry: 10.4% vs 7.3%(p<0.001). For witnessed VF patients, hospital discharge rates were 35.3 % with HUP CPR versus 25.1% CARES registry (P<0.001). The PEA neurologically intact hospital discharge rate was 10% in the HUP CPR group. CARES does not provide PEA outcomes separately. The poster with these data that was presented at the AHA Scientific Sessions in November 2023 is in Appendix 3.

• See Appendix 4a, 4b, 4c, and 4d for full peer reviewed publications.

• HUP CPR is not simply placing a patient’s torso at a prescribed angle. Animal studies showed multi-level sequential elevation is needed to establish optimal perfusion5. HUP CPR is a methodical process – it is not a single device but rather a technology-based approach to resuscitation that complements the current AHA-recommended standards of care.

• When the head is elevated too rapidly during HUP CPR, it is not as effective and can be harmful6. This is because the aortic pressure can decrease rapidly when the head is raised quickly, just like going from squatting to standing on a hot day. Performance of HUP CPR with a wedge results in too rapid an elevation of the head and that can lower aortic pressure and reduce brain blood flow. Furthermore, head and thorax elevation with a wedge varies greatly from person to person, which will result in suboptimal outcomes for many. We advocated NOT to perform HUP CPR this way years ago, when we showed CerPP approaching nearly normal values with a priming phase and gradual elevation over 2 minutes6. Performing HUP CPR as we recommend takes a minimum of 4 minutes to fully elevate. When we studied a more rapid rise over <30 seconds, it took 7 minutes to reach 50% of baseline CerPP values versus 3 minutes with a 2-minute rise. In addition, using a wedge does not elevate the thorax and it can be difficult to perform LUCAS CPR. Using a wedge could also increase the likelihood of LUCAS migration. The bottom line: it can be dangerous.

In the absence of obvious harm and with more and more positive data, AdvancedCPR Solutions continues to advocate for the widespread use of HUP CPR based upon the position that ‘HUP CPR should be considered as a complementary option to the best practice standard of care and current practice for first responder agencies that have resources for training, implementation, and mechanisms to track patient outcomes’.

• The EleGARD should not be used:
  • If the patient weighs more than 350 lbs./159 kg. (IFU, p. 5)
  • Anytime the patient cannot be correctly or safely positioned on the EleGARD (IFU, p. 5)
  • In standing water or snow (IFU, p. 12).

• The maximum elevation is not measured as an angle, but as a height. The Fully Raised thoracic elevation is approximately 8.5 cm/3.4 in. from supine, and the Fully Raised head elevation is approximately 25.3 cm/10 in. from supine (IFU, p. 25).

• Each light indicates 30% of the charge capacity (IFU, p. 11):
  • No lights – less than 30% charge capacity
  • One light – at least 30% charge capacity
  • Two lights – at least 60% charge capacity
  • Three lights – at least 90% charge capacity.

When the EleGARD System is in use, the battery lights cascade upward once the Up Button has been pressed to indicate elevation is in progress.

• If the battery fails during use, the EleGARD System will remain in its current position. Replace the expired battery with a charged battery, press the Power button to turn the EleGARD on, then press the appropriate up or down button to continue the elevation sequence.

• This button stops and/or resets the timer.
• A single quick push stops the timer.
• Holding this button for 3 seconds will reset the timer.

• If the patient is wearing a cervical collar or with bullneck (IFU, p. 7, p. 18).

• For Clinical Questions email: info@elevatedCPR.com
• For Sales & Service call: 763-259-3722 or www.elevatedcpr.com/service

1. CARES. CARES Summary Report. Web page. 2024. https://mycares.net/sitepages/uploads/2023/2022%20Non-Traumatic%20National%20Summary%20Report.pdf

2. Pepe P, Scheppke K, Antevy P, Crowe R, Millstone D, Coyle C et al. Confirming the clinical safety and feasibility of a bundled methodology to improve cardiopulmonary resuscitation involving a head-up/torso-up chest compression technique. Critical Care Medicine. 2019;47(3):449-455.

3. Bachista K, Moore J, Labarère J, et al. Survival for Nonshockable Cardiac Arrests Treated With Noninvasive Circulatory Adjuncts and Head/Thorax Elevation. Critical Care Medicine. 2024;52(2):170-181.

4. Moore J, Salverda B, Rojas-Salvador C, Lick C, Debaty G, Lurie, K. Controlled sequential elevation of the head and thorax combined with active compression decompression cardiopulmonary resuscitation and an impedance threshold device improves neurological survival in a porcine model of cardiac arrest. Resuscitation. 2020a;158:220-227.

5. Moore J, Salverda B, Lick M, et al. Controlled progressive elevation rather than an optimal angle maximizes cerebral perfusion pressure during head up CPR in a swine model of cardiac arrest. Resuscitation. 2020b;150:23-28.

6. Rojas-Salvador C, Moore J, Salverda B, Lick M, Debaty G, Lurie K. Effect of controlled sequential elevation timing of the head and thorax during cardiopulmonary resuscitation on cerebral perfusion pressures in a porcine model of cardiac arrest. Resuscitation. 2020;149:162-169.

7. Moore J., Holley J., Segal N., M. L. Consistent head up cardiopulmonary resuscitation haemodynamics are observed across porcine and human cadaver translational models. Resuscitation. 2018;132:133-139.

8. Moore J., Segal N, Lick M., Dodd K., et al. Head and thorax elevation during active compression decompression cardiopulmonary resuscitation with an impedance threshold device improves cerebral perfusion in a swine model of prolonged cardiac arrest. Resuscitation. 2017;2017(121):195-200.

9. Kim T, Shin SD, Song KJ, Park YJ, Ryu HH, Debaty G et al. The effect of resuscitation position on cerebral and coronary perfusion pressure during mechanical cardiopulmonary resuscitation in porcine cardiac arrest model. Resuscitation. 2017;113:101-107.

10. Ryu HH, Moore JC, Yannopoulos D, et al. The Effect of Head Up Cardiopulmonary Resuscitation on Cerebral and Systemic Hemodynamics. Resuscitation. 2016;102:29-34.

11. Debaty G, Shin SD, Metzger A, Kim T, Ryu HH, Rees J et al. Tilting for perfusion: head-up position during cardiopulmonary resuscitation improves brain flow in a porcine model of cardiac arrest. Resuscitation. 2015;87(2015):38-43.

12. Pourzand P, Moore JC, Metzger A, et al. Hemodynamics, survival and neurological function with early versus delayed automated head-up CPR in a porcine model of prolonged cardiac arrest. Resuscitation. 2023;194:110067.

13. Moore J, Bachista K, Quinn R, et al. The rapid use of automated head and thorax elevation with automated active compression decompression cardiopulmonary resuscitation and an impedance threshold device campared with national outcome data. presented at: NAEMSP; 2024;

14. Moore JC, Pepe PE, Scheppke KE, et al. Head and thorax elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival. Resuscitation. 2022;179:9-17.

15. Park Y, Hong K, Shin S, et al. Worsened survival in the head-up tilt position cardiopulmonary resuscitation in a porcine cardiac arrest model. Clnical and Experimental Emergency Medicine. 2019;6(3):250-256.

16. Moore J, Duval S, Lick C, et al. Faster time to automated elevation of the head and thorax during cardiopulmonary resuscitation increases the probability of return of spontaneous circulation. Resuscitation. 2021;170:63-69.

17. Moore J, Segal N, Debaty G, Lurie K. “The Do’s and Don’ts” of Head Up CPR: Lessons learned from the Animal Laboratory. Letter to the editor. Resuscitation. 2018;129:e6-e7.

18. Putzer G., Braun P., Martini J, I. N, al. e. Effects of head-up vs. supine CPR on cerebral oxygenation and cerebral metabolism – a prospective, randomized porcine study. Resuscitation. 2018;2018(128):51-55.

19. Jaeger D, Kosmopoulos M, Voicu S, et al. Cerebral hemodynamic effects of Head-up CPR in a porcine model. Resuscitation. 2023;193.

20. Shafer SL. ‘Heads Up’ on advances in CPR. ASA Monitor. 2024;88(2):1&4.

21. Moore J, Bachista K, Quinn R, et al. Comparison of rapid implemenation of automated head and thorax elevation with active compression decompression cardiopulmonayr resuscitation and an impedance threshold device versus national outcome data: A prospective observational study. presented at: American Heart Association Resuscitation Science Symposium; 2023;

Appendix 1:
Moore J, Segal N, Debaty G, K L. “The Do’s and Don’ts” of Head Up CPR: Lessons learned from the Animal Laboratory. Letter to the editor. Resuscitation. 2018;129:e6-e7.

Appendix 2:
Shafer SL. ‘Heads Up’ on advances in CPR. ASA Monitor. 2024;88(2):1&4.

Appendix 3:
Moore J, Bachista K, Quinn R, et al. Comparison of rapid implementation of automated head and thorax elevation with active compression decompression cardiopulmonary resuscitation and an impedance threshold device versus national outcome data: A prospective observational study. presented at: American Heart Association Resuscitation Science Symposium; 2023.

Appendix 4a:
Bachista K, Moore J, Labarère J, et al. Survival for Nonshockable Cardiac Arrests Treated With Noninvasive Circulatory Adjuncts and Head/Thorax Elevation. Critical Care Medicine. 2024;52(2):170-181.

Appendix 4b:
Moore JC, Pepe PE, Scheppke KE, et al. Head and thorax elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival. Resuscitation. 2022;179:9-17.

Appendix 4c:
Moore J ,Duval S, Lick C, Holley J, Scheppke K, Salverda B, et al. Faster time to automated elevation of the head and thorax during cardiopulmonary resuscitation increases the probability of return of spontaneous circulation. Resuscitation. 2021;170:63-69.

Appendix 4d:
Pepe P, Scheppke K, Antevy P, Crowe R, Millstone D, Coyle C et al. Confirming the clinical safety and feasibility of a bundled methodology to improve cardiopulmonary resuscitation involving a head-up/torso-up chest compression technique. Critical Care Medicine. 2019;47(3):449-455.